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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: W;t n e rs 6;4 z e, <br /> Street Address: 130 W. rd� nay <br /> City: 54-0Lk+0A Zip Code: 9S2Qy <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: r arou K b;ab <br /> Home Address: 54SO N, Hwy 99 , S+oCkkon CA 95212 <br /> Mailing Address: <br /> Telephone Number: 209 - 9 31 -111`7 <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: �a cr, 0,_s <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: G;+ w kc,r 5�ptjt <br /> Backflow Protection: Ye.5 ('iv* (,6,\'v3 4kktx S� kv lk S <br /> System to be used for Liquid Waste Disposal (Sewage): t o c\ to G;i 5oj\,kOCy JeAAC' S S <br /> Solid Waste Disposal to be provided: OA ;k� r1� eXZGlOsvre, <br /> Grease Interceptor: Y s '15 0 &(k\ <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 8/01/16 <br />